Sounds from a different drum

Sounds from a different drum.

Halsted R. Holman

J Clin Invest.

1971;

50(6)

:1369-1372.

https://doi.org/10.1172/JCI106616

.

ASCI Presidential Address

Find the latest version:

Proceedings of the Sixty-Third

Annual

Meeting of

The American Society for Clinical Investigation, Inc.

Atlantic City, New Jersey,

3

May 1971

PRESIDENTIAL

ADDRESS

Sounds from

Different Drum

HALsTEn

R.

HOLMAN

Some 14 years ago when I first came to these meetings

there was an air of excitement, optimism, and momen-tum. The impact of modern biology on medicine was widely appreciated, and the academic community was

striving to harness this new knowledge to understand

perplexing disease. During the subsequent decade bio-medical research flourished, and the buoyancy of the late 1950's was retained. In the last three or four years,

fortunes have changed. Biomedical investigation has

come under sharp criticism, support has been curtailed, and the atmosphere has become subdued and pessimistic, no less in our schools than at these meetings.

In general terms, the reason for the sudden sag in appreciation and support of medical research is the crisis inhealth care. We now know that precisely during the halcyon days of biomedical research, costs of medi-cal care were mounting astronomimedi-cally, the availability of care throughout the nation was not appreciably

im-proved, and the indicators of the state of the nation's health remained unimpressive. It is illustrative that health expenditures rose by 50% in the 1960's and that, in 1968, health insurance covered only 29% of personal

healthexpenditures.

The current problems in biomedical research and training have been thoroughly examined by others. I shall mention only briefly what they have explored in detail. Medical research and especially clinical investi-gation arose in significant part from the incapacity of physicians to understand disease and hence to care for patients effectively. It was a response to the health care crisis of yesteryear created by medical ignorance. The fruits of research in the past two decades are striking in terms of illnesses understood, treatments devised, and

suffering alleviated. We are on the threshold of even moreimpressive gains against major causes of morbidity such as cardiovascular disease, malignancy, emotional

illness, and arthritis. Virtually every time that

calcula-tions have been made on the cost effectiveness of

re-search, the money saved through reduction in morbidity,

diminished hospitalization costs, and increased work productivity, has far outweighed the costs of research. Thespectacular increase in cost of medical care is not

due to costsof research. As anation, wespendon medi-cal research something less than 5% of our total expend-itures for health care, a figure quite consistent with research investment in other developing activities. This relationship may be viewed in another way. There are

17 million arthritics requiring medical care in this country. Arthritis is the second leading cause of limita-tion of activity. The annual cost of arthritis in terms of lost income and medical expenses is $3.6 billion. The estimated loss in taxes to the government due to activity limitation from arthritis is $200 million annually. The total national expenditure on research in arthritis is but $15 million; this is only 7.5% of the lost tax income alone and 0.4% of the cost of the illness to the public. Despite the rapid recent rise in medical faculty size, the total number of faculty members, who constitute the majority of medical investigators, is approximately

6% of the total number of physicians in the country. The university hospitals where they work account for roughly 20% of hospital admissions and outpatient visits. In the absence of substantial direct support for the costly process of medical education, the development of medical schools and medical faculties has been in substantial part subsidized by federal training and re-search programs. It can accurately be said that much of what is basic in our medical knowledge and practice today derives from rigorous study of disease and pa-tients, especially as developed through the National Institutes of Health. Our research efforts are hardly excessive in comparison with the magnitude of either

curtail our effort in this area would be to mortgage the future health of the nation.

We must recognize however that defense of biologi-cal and clinibiologi-cal research, no matter how accurate or

spirited, does not address the problem. Just as it is meaningless to attack research as a fundamental cause of the health care crisis, it is equally wide of the mark to defend research without addressing the origin of that crisis.

Certain general characteristics of the health care

crisis are evident. Perhaps a third of the population of

this country receives good medical care; the remainder receives only adequate care or none at all. Amongst those whose care is poor or inadequate are most of the minority people and those with lower incomes, people who suffer a disproportionately high incidence of dis-ease. Medical care when it is available is predominantly curative not preventive. The costs of hospitalization,

special procedures, and physician services have risen so steeply that care for moderate illness is expensive, and

the cost of a serious illness is catastrophic. Throughout the country physicians are inequitably distributed in terms both of geography and medical skills. General medical care to the community is less and less readily available. In the past decade physicians' fees have risen

at twice the rate of the Consumer Price Index. The physician, once firmly atop a pedestal in public esteem, is now listing heavily under charges of avarice, hy-pocrisy, and self-seeking.

As these problems have become insistent, the profes-sion has been increasingly challenged concerning its efforts to remedy matters. In medical schools the

chal-lengers have seen, amidst vigorous biomedical research,

a much smaller attention to the health crisis. They rightly view the schools as public institutions built and

nourished with public funds. Small wonder then that

they call into question the current activities of schools and that public representatives announce that they shall henceforth use public monies to force redirection upon schools.

Under the onslaught of criticism, we and our institu-tions have undertaken various new acinstitu-tions. We are enlarging class size, training more nonphysician health personnel, analyzing our institutional health care pro-grams, diversifying curricula, and joining in com-munity health projects. This is good. I think it is fair

to sayhoweverthat these steps at times have been taken

as expedient measures to decompress hostility or to qualify us for continued public support, rather than as

a result of searching redefinition of the obligations of the profession and its schools. As a consequence there is a distinct possibility that many of our new programs will be inadequately designed or sustained, will be

in-efficient or fail, and may result in heightened anger anddisaffection amongst thepublic.

This country needs a system of medical care,

teach-ing, and research, which provides all citizens with attention of high caliber when they are ill, which ad-dresses itself meaningfully to the prevention of illness,

which is humane yet efficient, and which creates

en-thusiastic public support for development

including

they are far from a reality today. Their achievement is a challengeto us and our institutions, which is more

immediate and profound than any in medicine our gen-erationhas faced.

Knowledge is the product of centuries of man's

ex-periences, work, and thought. It is the heritage of all people; the contributions of each man to the body of knowledge are based upon the efforts of countless others before him. The social utility of knowledge is to permit man to understand himself and his surroundings, and to

enable him to better his life and those of others. Knowl-edge in this sense is not a private possession of those who have attained it; their responsibility includes the transmission of knowledge to all who wish and need it. The ideal role of the physician embodies this relation-ship perfectly. He learns what those before him have created, and has the purpose of applying it for the health and well-being of his fellowman. His social role is therefore one of translating human knowledge for the benefit of individuals or groups. It is his obligation

to seek means whereby each citizen benefits from the best ofmedical knowledge.

The organization of medical care- in this country has not been based upon these premises. At its heart has been the concept that, once medical knowledge is learned by thephysician, it is his possession to sellto those who can afford it. The physician commonly sets the price, and those who cannot meet it are not his primary

con-cern. Guilds of physicians have functioned to restrict thenumber of physicians and to protect the price struc-ture of medical care rather than to strive to guarantee carefor all people. In its baldest form, this is a usurpa-tion of public knowledge for private gain. The violausurpa-tion of social trust which it exemplifies is all the more pro-nounced when the education of the physician and even

his private fees are subsidized by public funds. The contradiction is further aggravated when schools of

medicine, enjoying large public subsidy, fail to apply to the study and solution of the health care crisis an

energy and a rigor similar to those applied to biomedi-cal research.

The conflict between the public nature of knowledge and its use for private gain may be viewed in another context. As science and technology have grown in power and scope, they have greatly increased the

pacity of man to change nature for good and ill. The uses ofthese powers whether in industry, agriculture, or ur-ban planning have an impact far beyond the immediate products, respectively, of an automobile manufactured,

a crop freed of pests, or a slum replaced by office buildings. The establishment of public control over such actions in order to protect the enduring interests of so-ciety has become a major political issue. No less a problem has appeared in medicine. Science has trans-formed the physician from a kindly but impotent sym-pathizer with the patient into an intervener in biological processes, who alters the patient through an increasing array of drugs and procedures. Not all of these inter-ventions are successful; many leave the patient changed both physically and mentally. Amongst the obligations which these new powers place upon the physician is the education of the patient concerning the consequences of

different actions and the choices before him, and the involvement of the patient or his family in the decisions concerning the course of action. Thus the relationship of the physician to the patient has become a microcosm of the larger relationship between science and society.

Our success in defining the doctor-patient relationship in this setting will condition profoundly the nature of the relationship between the profession and citizens in years to come.

Fromthese generalizations I think certain conclusions

flow for those of us in medical education and research. First, just as many years ago we defined the absence of

understanding of disease as the fundamental

impedi-ment to improved medical care and mounted a con-certed effort to introduce science into medicine, now we must define those factors which are limiting the

avail-ability of medical care and undertake actions to over-come those limitations. Subjects which demand atten-tioninclude:

-development of integrated, regionalized health care systems which provide comprehensive care, avoid duplication, and are economically efficient;

-training and testing of nonphysician health

profes-sionals and their insertion into care delivery pro-gramsand health care teams;

-re-evaluation of the role of institutions such as hos-pitals to diminish utilization by transferring func-tions to less expensivefacilities;

-rigorous analysis of the learning process in clinical medicine so that the structure of clerkships and post-graduate training can be based upon the content and speed of learning rather than upon the convenience

ofthe institution;

-redesign of medical information handling so that practicing physicians can evaluate and learn from their own practices and can engage in clinical in-vestigation in the course of their practice; and

-the development of educational programs in

com-munityhospitals and clinics, which will sustain physi-cians and other health personnel at a high level of performance throughout their practicing lifetimes. These and similar undertakings will require the same

attention and imagination that mark good biological investigation and teaching. Such aneffort need not be a substitute for, nor a competitor with, clinical care and biomedical research; rather it needs to be a new third major area of concentration. Just as good biological research heightened extraordinarily our capacity to give good medical care, so success in these programs will add amajor dimension to health in our country.

Second, an alliance is needed between our clinical departments and the disciplines of economics, sociology, management, and law, which will bring them to focus on the health care crisis. This alliance would be analo-gous to that with the basic sciences which provided the foundation for the burst in biological understanding of disease. In some cases one can visualize these disci-plines establishing residence in medical schools; in other instances we should reach out to them on cam-puses and in communities. One consequence will be the training ofa newtype of physicianwho possesses

simul-taneous skills in clinical medicine and these

nonbio-logical disciplines, and who will be an

analogue

women will then join and change our faculties and provide leadership to these new programs. A more important consequence will be the operational

recogni-tion that medical care represents a major intersection of science and social organizing, and our schools will

begin to reflect that reality in their composition and activities.

Third, recognizing the social nature of medical care,

we need to join with citizens and their representatives in the planning and conduct of new health care pro-grams. Fully developed, this approach will have the most far-reaching impact. It will also be the most diffi-cult to do well. It may be visualized most easily in

terms of community programs such as those organized

by the Comprehensive Health Planning Agencies. There, ours will be the classical advisory role. But much more is needed. If good medical care requires a

partnership of physician and patient, then the

organiza-tion of health delivery systems requires a partnership

of the profession and citizens. In the partnership physi-cians will have a significant voice in the design and function of a health care system; citizens will have a

significant voice in the types of services provided and the performance of the installations in which physi-cians function, teach, and do clinical investigation.

No longer will the physicians dominate the decisions;

great difficulty. Are we prepared for this ? Not well, if at all. Our traditions are more geared to domination,

or to the form of consultation but not the substance.

We will need faculty and administrations who perceive community problems, who can work imaginatively at the interface between science and society, and who are gifted at community organizing. We will need to seek and be responsive to community views concerning the quality of our services, the patterns of our teaching, and the sensitivity and purposes of our research. Such circumstances are not entirely foreign to us. We have long dealt with Boards of Trustees or Directors and Visiting Committees of Laymen. Their successors in

the new relationship however will be far more repre-sentative of the community served, far more involved and critical, and probably far more helpful to us. If we

can bring our minds and our schools to welcome this,

or at least to tolerate it, the needed partnership will be born.

It is often argued that these approaches are not the responsibility of educational institutions and that by embarking upon them we will damage the quality of existing programs. This is a common argument against

change and was employed against the introduction of science into clinical medicine. This Society and most of

our departments stand as evidence against its validity in that setting. Expansion to encompass science im-proved rather than harmed clinical medicine. In this

new setting, change will be harmful only if we do the job poorly. If it is true that our fundamental obligation is the improvement of health, and if there are major obstacles to that improvement at present, then there

can be no greater obligation for institutions of medical

education and research than to address these impedi-mentsvigorously.

It is also argued that such departures will signifi-cantly alter our academic institutions to their detri-ment. That they will be altered is true and desirable. That the alteration will be detrimental is untrue.

In-stitutions have no intrinsic worth; they exist to serve purposes. Their value is gauged by the quality of their performance. The scientific revolution changed medical institutions strikingly. New change is now essential for

us to meet new obligations. History is cluttered with the rubble of institutions which could not respond to

their times.

Institutions have character, even personality. They

are warm or cold, responsive or rigid, farsighted or

complacent. These attributes determine our allegiance

to them. Institutional immobility is quickly recognized, especially by the young, and leads to attrition in alle-giance, a condition widely apparent in education today.

It will be precisely our capacity to welcome and to

ac-complish change which will make our institutions

ex-citing and vibrant places to work in the future. Finally, it is asserted that such changes will under-mine our scientific thrust. I would argue the converse; they are essential to safeguard it. Because scientific knowledge is public knowledge, because its development is publicly sponsored, and because its effects upon the public are profound, science must be understood, used, and appreciated by the public. Through their involve-ment in the planning and organization of medical care, citizens will come to understand its complexities, and its educational and scientific needs. Thereby, physicians, educators, and citizens will become allies in support of the extension of knowledge, not adversaries. Thereby also the conditions will be created for both health and science to thrive.

It is easy to criticize others for the health crisis and to leave to them its resolution. Both the American Medi-cal Association and the Pentagon deserve to be sMedi-calded for their respective, deep contributions to the crisis. But can we in clinical departments recognize our own

culpability, born of neglect and myopia, and change ourselves sufficiently to make a critical contribution to the solution ? The stakes are high; the health of our nation and the health of our medical institutions are both in the balance. Nothing short of new directions and changed institutional character and structure will

do. The changes will be difficult, especially if we are to assure quality in the new. But if we succeed, we will recapture enthusiasm, excitement, and the exhilaration of accomplishment. And it will not only be present at these meetings, but also everyday in our institutions.